On October 12, 2007, a series of news items were published in the Spanish newspaper El País regarding serious failures that occurred in different countries of the European Union.
Analyzed the information, it can be deduced from it the lack of application of fundamental principles regarding quality and safety.
Firstly we have the headline "Lack of hygiene causes death to 90 people in three English hospitals"; Later in the comments, it is reported that the deaths were caused by three outbreaks of infections caused by the Clostriudium difficile bacteria that affected 1500 patients between April 2004 and September 2006. It is clarified that these three hospitals are managed by the private consortium Maidstone and Tumbridge Wells.
The investigation into the case was initiated by specialists from the National Health System of England (NHS) following complaints received about the lack of hygiene in the hospitals managed by the aforementioned consortium.
The researchers concluded that these problems were mainly due to the fact that health personnel made more effort to meet the objectives of reducing waiting lists (speed of care) set by the Government than in caring for patients. The nurses were "too busy" to waste time washing their hands and complying with the hygiene regulations in force at the center. According to the researchers, everything from “diarrhea smell” to sheets used by former patients or patients forced to relieve themselves in bed were observed because nobody had time to accompany them to the bathroom.
What can we extract from this first news? Firstly, the total lack or absence of an ethical commitment by both the authorities and the staff. Second, the lack or lack of a statistical follow-up (SPC) that allows alerting about the anomaly (the cases occurred between 2004 and 2006). The third aspect is the much-mentioned numerical goal setting (punished not without its just cause by Deming) regarding the reduction of waiting lists set by the government, and carried out by private managers without increasing resources or improving the use of them, but simply pressing to obtain them at any cost.
Second headline "One out of every 13 patients admitted to a hospital center in Spain acquires an infection" As stated in the newspaper "experts assume that acquiring a nosocomial infection is an assumed and inevitable risk when staying hospitalized". It is necessary to clarify to these alleged experts that the number of recognized cases implies a sigma level of 2,926 or what is the same 76,923.08 failures per million opportunities, which represents an absolutely inadmissible figure for the current quality parameters (having Keep in mind that organizations of excellence pursue a level of 6 sigma, which is representative of only 3.4 defects per million opportunities).
Among the details contained in the note it is said: "Finally, health personnel, if they neglect their hygiene, may be a vehicle for the transmission of microorganisms from one patient to another" (sic).
Finally it is clarified that for the year 2005 the number of deaths attributable to an infectious process is only 7,500 people, or what is the same only 2% of the almost 400,000 deaths. This shows the total lack of knowledge on the part of the journalist, but his absence of ethical principles, since the death that can be avoided is in itself something more than serious, it is very serious. You should be aware that the affected within that "small" 2% could be him or one of his loved ones.
Third headline "Catalan health implanted defective lenses in 20 cataract patients"; Then she continues "The Catalan Institute of Health (ICS) has been forced to repeat dozens of cataract operations after detecting a batch of defective lenses that were implanted in patients operated on in the network of public hospitals in Catalonia six years ago."
He continues later "The intraocular lenses are of the H60M / SN model and were part of a defective batch served by the Bausch & Lomb laboratories to different hospital centers." Finally, it is clarified: “ICS knew about the problem since 2001 through the laboratories themselves, which removed the contact lens model from the market. However, they chose to inform each patient "individually" as they were "reviewed", instead of issuing a statement, to avoid "alarmism," explained Dr. Montserrat Figuerola, deputy director of ICS Healthcare Affairs " the defective IOLs have caused opacity and vision loss many patients.
Firstly, we have a lack or absence of control at the source, that is, in Bausch & Lomb, then there is a lack of control prior to the use of the material (error-proof systems - Poka Yoke), thirdly, the serious one was incurred mistake of not giving immediate notice to those affected in order to avoid further damage. Many organizations, even with the best quality systems, can make mistakes, but when they become aware of it, they adopt corrective measures for the users or consumers of their products, something that clearly was not done here. Dr. Figuerola says "today perhaps we would have reported globally."
Fourth headline: "This girl is not ours." "Two couples raise two babies for ten months who were exchanged at birth in a hospital in the Czech Republic." Questions is this error admissible? Can we accept a failure of this nature in one of the countries with the highest cultural level in the world? What failure here?
First, there is no error-proof system, second, the staff lacks the minimum level of concentration to avoid errors, third, there is no training for service quality.
Last conclusions
First: you can exchange your baby in a "first world" country.
Second: you or someone close to you may die simply by entering a hospital center, due, among other reasons, to the total lack of hygiene of your workers, since speed is better than quality of care.
Third: even if the lenses or another component are from a company that presumably follows the criteria of excellence of the EFQM (European Foundation for Quality Management), your health is in danger.
Fourth: Not only in Africa or Latin America are serious mistakes made, sometimes they are much greater in the central countries, as when it is reported that in the United States four people contracted HIV from the same donor in a transplant.
